1. Fascial repair Douglas Tincello Professor of Urogynaecology and Consultant Gynaecologist

2. Outline What are the relevant fascial structures? Do we know what fascial repair is? Do we know how to repair fascia? Does it work? I didn’t! Tincello DG Kuwait Feb 16 th -18 th 2013

3. What are the relevant fascial structures? Delancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am.J.Obstet.Gynecol. 1992;166:1717-24. Level 1 Level 2 Level 3

4. Do we know what fascial repair is? Questionnaire survey of BSUG members (Freeman RM, Smith AH, Glazener CMA) What do you understand by “site-specific defect”? Do you think they can be recognised at surgery? If so, how? Do you think they need customised management? If so, how? If a procedure is not usual practice, would you do it within an RCT? Tincello DG Kuwait Feb 16 th -18 th 2013

5. Do we know what fascial repair is? Specific: “apical defect …loss of uterosacral ligament” Vague: “a tear in a recognisable bit of tissue” What do you understand by “site-specific defect”? Do you think they can be recognised at surgery? If so, how? Do you think they need customised management? If so, how? If a procedure is not usual practice, would you do it within an RCT? Tincello DG Kuwait Feb 16 th -18 th 2013

6. Do we know what fascial repair is? Specific: “apical defect …loss of uterosacral ligament” Vague: “a tear in a recognisable bit of tissue” Understand? Specific: 5 Vague: 25 Do you think they can be recognised at surgery? If so, how? Do you think they need customised management? If so, how? If a procedure is not usual practice, would you do it within an RCT? Tincello DG Kuwait Feb 16 th -18 th 2013

7. Do we know what fascial repair is? Specific: “apical defect …loss of uterosacral ligament” Vague: “a tear in a recognisable bit of tissue” Understand? Specific: 5 Vague: 25 Recognised? Yes: 28 No: 2 If so, how? Do you think they need customised management? If so, how? If a procedure is not usual practice, would you do it within an RCT? Tincello DG Kuwait Feb 16 th -18 th 2013

8. Do we know what fascial repair is? Specific: “apical defect …loss of uterosacral ligament” Vague: “a tear in a recognisable bit of tissue” Understand? Specific: 5 Vague: 25 Recognised? Yes: 28 No: 2 If so, how? Specific: 5 Vague: 24 Do you think they need customised management? If so, how? If a procedure is not usual practice, would you do it within an RCT? Tincello DG Kuwait Feb 16 th -18 th 2013

9. Do we know what fascial repair is? Specific: “apical defect …loss of uterosacral ligament” Vague: “a tear in a recognisable bit of tissue” Understand? Specific: 5 Vague: 25 Recognised? Yes: 28 No: 2 If so, how? Specific: 5 Vague: 24 Customised Mx? Yes: 25 No: 5 If so, how? If a procedure is not usual practice, would you do it within an RCT? Tincello DG Kuwait Feb 16 th -18 th 2013

10. Do we know what fascial repair is? Specific: “apical defect …loss of uterosacral ligament” Vague: “a tear in a recognisable bit of tissue” Understand? Specific: 5 Vague: 25 Recognised? Yes: 28 No: 2 If so, how? Specific: 5 Vague: 24 Customised Mx? Yes: 25 No: 5 If so, how? Specific: 7 Vague: 18 If a procedure is not usual practice, would you do it within an RCT? Tincello DG Kuwait Feb 16 th -18 th 2013

11. Do we know what fascial repair is? Specific: “apical defect …loss of uterosacral ligament” Vague: “a tear in a recognisable bit of tissue” Understand? Specific: 5 Vague: 25 Recognised? Yes: 28 No: 2 If so, how? Specific: 5 Vague: 24 Customised Mx? Yes: 25 No: 5 If so, how? Specific: 7 Vague: 18 Not usual RCT? Yes: 24 No: 5 Tincello DG Kuwait Feb 16 th -18 th 2013

12. Do we know how to repair fascia?  “Traditional” surgery  Midline plication of fascia during anterior repair  Midline plication ± levator plication during posterior repair  “Site specific” surgery  Lateral paravaginal defects  Fascial defect rectocele repair  Sacrocolpopexy or sacrospinous fixation Tincello DG Kuwait Feb 16 th -18 th 2013

14. Anterior compartment surgery  Three anatomical types of cystocele (Nichols DH. Cystocele. In Nichols DH, Clarke-Pearson DL, eds: Gynecologic, Obstetric & Related Surgery, 2 nd Edition, Missouri, 2000, Mosby Inc.)  “Anterior cystocele” (pseudocystocele)  Rotation of urethra due to separation of pubourethral ligament  Distal to the inter-ureteric ridge  “Posterior cystocele” (true cystocele)  Stretch of vaginal wall/fascia without loss of lateral supports  Proximal to inter-ureteric bar  Loss of vaginal rugae  Persistence of lateral vaginal sulci  “Distension cystocele” Tincello DG Kuwait Feb 16 th -18 th 2013

15. Anterior compartment surgery Anterior cystocelePosterior cystocele Nichols DH. Cystocele. In Nichols DH, Clarke-Pearson DL, eds: Gynecologic, Obstetric & Related Surgery, 2 nd Edition, Missouri, 2000, Mosby Inc. Tincello DG Kuwait Feb 16 th -18 th 2013

16. Anterior compartment surgery  Paravaginal defects (Richardson AC et al Am J Obstet Gynecol 1976;126:568-71)  Traumatic damage to lateral fascial supports of anterior vagina  Loss of one or both lateral vaginal sulci  Persistence of vaginal rugae  Anterior vaginal wall relaxed and does not move with pelvic floor contraction (Baden WF & Walker T. Evaluation of uterovaginal support. In Baden WF, Walker T, eds: Surgical repair of vaginal defects. Philadelphia 1992, JB Lippincott)  “Displacement cystocele” Tincello DG Kuwait Feb 16 th -18 th 2013

17. Paravaginal defects- prevalence  “Much less common” than midline defects (Nichols DH. Cystocele. In Nichols DH, Clarke-Pearson DL, eds: Gynecologic, Obstetric & Related Surgery, 2 nd Edition, Missouri, 2000, Mosby Inc.)  85-90% of cases of urethrovaginal prolapse (Richardson AC et al Am J Obstet Gynecol 1976;126:568-71) (Grady Bruce R et al Urol 1999;54:647-51)  Often coexist with central defects (Shull BL et al Am J Obstet Gynecol 1994;171:1429-39)  Uncommon finding in my practice  Uncommon finding in UK colleagues’ practice Tincello DG Kuwait Feb 16 th -18 th 2013

18. Grady Bruce R et al Urol 1999;54:647-51 Paravaginal defect repair  Abdominal or vaginal approach  Re-attach lateral vaginal edge/fascia to arcus tendineus  Ischial spine anteriorly towards Cooper’s ligament Tincello DG Kuwait Feb 16 th -18 th 2013

19. Paravaginal defect repair  Abstract only reviewed  60 women (Richardson AC et al Am J Obstet Gynecol 1976;126:568-71)  223 women (Richardson AC et al Obstet Gynecol 1981;57:357-62)  Full papers reviewed  52 women (Grady Bruce R et al Urol1999;54;647-51)  149 women (Shull BL & Baden WF Am J Obstet Gynecol 1989;160:1432-9)  66 women (Viana R et al Int Urogynecol J 2006;17;621-3)  100 women (Young SB et al Am J Obstet Gynecol 2001;185:1360-6)  62 women (Shull BL et al Am J Obstet Gynecol 1994;171:1429-39)  bilateral defects Tincello DG Kuwait Feb 16 th -18 th 2013

20. Retrospective series-abstract only  (Richardson AC et al Am J Obstet Gynecol 1976;126:568-71)  60 women 92% cure at follow up (3 – 48 months)  (Richardson AC et al Obstet Gynecol 1981;57:357-62)  223 women, surgery for stress incontinence “Functionally satisfactory results in over 95%... 2 to 8 years follow up” Tincello DG Kuwait Feb 16 th -18 th 2013

21. Abdominal approach  (Grady Bruce R et al Urol1999;54;647-51)  52 women (27 also had fascial sling for ISD)  Surgery for cystocele and incontinence  Follow up 17 months Incontinence cure 79% Cystocele cure 92%  (Shull BL & Baden WF Am J Obstet Gynecol 1989;160:1432-9)  149 women; cystocele and incontinence  Follow up 18 months Incontinence cure97% Cystocele cure95% Tincello DG Kuwait Feb 16 th -18 th 2013

22. Abdominal approach  Shull BL et al Am J Obstet Gynecol 1994;171:1429-39  100 women with bilateral defects and midline repair  Median follow up 2 years  Anatomic cure 79% (does not specify site) Tincello DG Kuwait Feb 16 th -18 th 2013

23. Vaginal approach  Young SB et al Am J Obstet Gynecol 2001;185:1360-6  100 women; midline and paravaginal repair done vaginally  84 women 6 week follow up; 55 one year Paravaginal cure98% Midline cure78%  (Viana R et al Int Urogynecol J 2006;17;621-3)  57 of 66 women; vaginal approach for cystocele only  Follow up 18 months  47 unilateral defects; 5 central defect; 5 bilateral Cystocele cure (12/12)92% Tincello DG Kuwait Feb 16 th -18 th 2013

24. Paravaginal defect repair-summary  Retrospective series evidence  Anatomical correction – variable but generally good  Cure of associated incontinence  Many additional procedures done  Randomised trials? Long term follow up? (Maher C et al Int Urogynecol J 2011;22:1445-57) (Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub4)  Trials of anterior vaginal wall repair versus the abdominal paravaginal repair in the management of cystocele  “No trials identified” Tincello DG Kuwait Feb 16 th -18 th 2013

26. Rectovaginal fascia (Denonvillier’s fascia)  Attachments  Uterosacral ligaments above  Arcus tendineus laterally  Perineal body below  Function  Support of posterior vagina  Vertically and laterally  Support of perineal body  Prevention of descent Richardson AC. Clin Obstet Gynecol 1993;36:976-83. Tincello DG Kuwait Feb 16 th -18 th 2013

27. Rectovaginal fascial defects  Discrete defects in cadavers and patients  Repair of defect results in correction of rectocele (Milley PS, Nichols DH. Anat Rec 1968;163:443-52.) (Richardson AC. Clin Obstet Gynecol 1993;36:976-83.) Tincello DG Kuwait Feb 16 th -18 th 2013

28. Fascial defect rectocele repair  Retrospective series (100% cases)  69 women (Cundiff GW et al Am J Obstet Gynecol 1998;179:1451-6)  66 women (Kenton K et al Am J Obstet Gynecol 1999;181:1360-3)  125 women (Porter WE et al Am J Obstet Gynecol 1999;181;1353-8)  Prospective series  67 women; 96% specific defects (Glavind K et al Acta Obstet Gyn Scand 2000;79:145-7)  42 women; 100% specific defects (Singh K et al Am J Obstet Gynecol 2003;101:320-4) Tincello DG Kuwait Feb 16 th -18 th 2013

29. Retrospective series  Cundiff GW et al Am J Obstet Gynecol 1998;179:1451-6  Inferior or combined defects 86%  49 of 69 follow up at median 12 months Anatomic cure 82% Constipation 84% Dyspareunia 66%  Kenton K et al Am J Obstet Gynecol 1999;181:1360-3  46 of 66 follow up at 12 months Anatomic cure 77% Bulge95% Constipation 62% Dyspareunia 72% Tincello DG Kuwait Feb 16 th -18 th 2013

30. Retrospective series  Porter WE et al Am J Obstet Gynecol 1999;181;1353-8  114 of 125 follow up at median 12months Anatomic cure 77% Bulge90% Constipation 43% Dyspareunia 92% Tincello DG Kuwait Feb 16 th -18 th 2013

31. Prospective series  Glavind K et al Acta Obstet Gyn Scand 2000;79:145-7  3 month follow up (all women) Anatomic cure 95% Constipation 85% Dyspareunia 75%  Singh K et al Am J Obstet Gynecol 2003;101:320-4  33 of 42 follow up at18 months Anatomic cure 93% Bulge87% “Bowel symptoms”62% Tincello DG Kuwait Feb 16 th -18 th 2013

32. Fascial defect rectocele repair-summary  Retro/prospective series evidence  Anatomical correction  Protrusion symptoms  Evacuation difficulties  Less good for constipation  Randomised trials? Long term follow up? (Maher C et al Neurourol Urodyn 2008;27:3-12) (Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub3)  Only four trials in total  Paraiso MFR et al Am J Obstet Gynecol 2006;195:1762-71 Tincello DG Kuwait Feb 16 th -18 th 2013

33. Fascial defect rectocele repair  Paraiso MFR et al Am J Obstet Gynecol 2006;195:1762-71  Colporrhapy vs site specific repair vs SSR + porcine dermis  96 women; 93% completed and followed 18 months 12 month data Anatomic cure Functional cure Colporrhapy (28)86%85% Site-specific repair (27)78%85% SSR + graft (26)54%85% Colporrhapy 83% Site specific 60% SSR+ graft 48% Tincello DG Kuwait Feb 16 th -18 th 2013

35. Apical support surgery  Must correct apical support  Cannot identify level II defects if you don’t  Sacrocolpopexy, sacrospinous fixation, posterior IVS etc  Randomised trials (Maher C et al Neurourol Urodyn 2008;27:3-12) (Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub3)  3 trials of abdominal sacral colpopexy versus vaginal sacrospinous colpopexy  Less vault recurrence RR 0.23, 95% CI 0.07 to 0.77  Less dyspareuniaRR 0.39, 95% CI 0.18 to 0.86  Fewer re-operationsRR 0.46, 95% CI 0.19 to 1.11 Tincello DG Kuwait Feb 16 th -18 th 2013

36. Final conclusions  Do we know what fascial repair is?  Paravaginal defect repair  Fascial defect posterior repair  Is fascial repair effective?  Appears to correct cystocele ± urinary incontinence  Appears to correct anatomic and symptomatic rectocele  Not so good for constipation  Should I change what I do?  Keep a look out; you’ll find some!  Interrupted PDS for rectovaginal septum repairs  Enrol in any large RCTs being organised Tincello DG Kuwait Feb 16 th -18 th 2013